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Veterans and Trauma in Group Therapy Cary E. Rothenburger, M.Ed., LCSW

Abstract

The purpose of this article is to show the importance that group therapy has played and continues to play in working with veterans. Veteran groups from World War II to present have had a positive impact on many veterans. The majority of articles references are from 1973 to 2015 and focus on the work done with the Vietnam veterans. From the authors’ personal experience as a group therapist and a Vietnam veteran, group therapy has shown to be very useful, practical, and successful model to follow for veterans. Veterans report that both informal open support/rap groups and closed therapy groups have helped. The support/rap group is an opportunity for veterans to be a part of a less threatening and confronting group and experience the advantages of being part of a group. This also provides the group therapist with an opportunity to provide resources for veterans and to assess what would be the next best step for them. The closed therapy group provides a long term and intense experience. This article is organized in three sections. One, a brief history of veteran groups. Two, examines the unique advantages and challenges for veterans in group therapy. Three, a brief review of therapeutic techniques that have been used in group. I was leading an inpatient group for a hospital in Boston and one of the Vietnam veterans in the group, Tom, shared a story. Tom had killed his best friend, Ian. Their platoon was assigned a mission deep within enemy territory. They encountered fierce opposition, and were outnumbered 10 to 1. Five men were killed and three were wounded, including Ian. The remainder of the platoon was able to retreat to a position where they could hide in dense jungle vegetation. Ian had attempted to throw back in enemy hang grenade that exploded before he could get it away. He was bleeding from a piece of shrapnel that was still stuck in his gut and his right hand had been blown off. Tom did his very best to stop the bleeding with a compression bandage on his stomach made up of a rag he had torn off the uniform of a dead body and he used the dead man’s belt as a tourniquet around Ian’s arm. There was no medic on the mission and nobody had any morphine. It was all Ian could do to keep his expressions of pain to a continuous, low, agonizing moan. Enemy soldiers were approaching; Tom could hear their slow deliberate steps on the jungle floor. Those still alive

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were whispering to Tom to keep Ian quiet or they’d all be dead. Instinctively Tom pulled his buddies head close to his chest to quiet the moans. Ian suffocated to death in Tom’s arms that night. Tom had been able to talk to his individual therapist and this was helpful. However, to tell his story in front of a group of veterans was very different. He had wondered for years, how anyone could understand and forgive him. He could not forgive himself, because he could not understand how he had been capable of such an act. To his surprise the other group members could and did forgive him. Some of the responses were, “you did the only thing that you could do, your strength and bravery saved all those lives, and I think that your best friend wanted the pain and suffering to end.” Necessity is the mother of invention, and the birth of group therapy was another manifestation of that truth. During World War II, the Veterans Administration found itself unprepared for the great number of returning veterans experiencing the nonphysical wounds of war (primarily what has since been labeled PTSD). My father was a World War II marine who fought in some of the fiercest battles in the South Pacific. He suffered great psychological aftermath with little acknowledgment and with no professional help. He would awake in the middle of the night in a pool of sweat next to his 18-year-old bride. The yelling and screaming were difficult enough, but waving around a fully loaded 45 automatic was more than she could handle. He hid and locked both the 45 and the ammunition, but still it would somehow end up under his pillow. As a matter of practicality and necessity, the few medics, nurses and doctors available began seeing traumatized veterans in groups. At that time there was little awareness of the psychological and physiological impact of war trauma, but it was observed that groups of veterans helped alleviate post war issues (Rutan, 2014a). The organic groups that began to form after WWII were a way for veterans to pass the time until they were reunited with their loved ones. Not all groups were called therapy groups, but nonetheless they were therapeutic. The shipboard poker games, sharing pictures of sweethearts, and the quiet conversations from bunk to bunk were important to begin to defuse the inexplicable inhumanity to man they had experienced. Groups of two or groups of ten, all provided an “attachment solution” (Frichionne,) as the Naval troop carriers plied their way home.

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It takes a while to say goodbye. We have a strong instinct to belong to small groups defined by clear purpose and understanding--"tribes." This tribal connection has been largely lost in modern society, but regaining it may be the key to our psychological survival (Junger, 2016). Veteran support/rap groups and closed therapy groups are a way for veterans to find their civilian tribe and begin to heal the wounds of war. My return from Vietnam signaled a sudden and total loss of my tribe. The men that had become brothers, men that I had spent all of my time with and come to respect and admire were scattered around the country. I did not see it as a loss at the time, it was just time for to the next chapter of my life. I moved back to Concord, Mass where my father was a high school teacher and my family enjoyed a seemingly all American suburban cozy life. The drinking and drugs that had been a way of life in the military were now a way to cope with civilian life. And it worked for a while. I was just fine thank you very much, and the more that I could forget about any involvement in Vietnam, the better. I was surrounded by a culture of great privilege and wealth. Only one of the guys I hung out with in high school had gone to Vietnam, the rest received draft deferments because of their connections, wealth, or their ability to stay in college. Unwilling to look at any problems I may have had and surrounded by peers that really had no idea of what I’d been through, it never occurred to me that talking to other veterans may be helpful. This combined with my survivor’s guilt, kept me shut down. I didn’t want to think about flying over those fire fights on the ground and imagining where those poor guys had to spend their nights in the jungle. As a radar operator on a P3 Orion I got to fly back to a safe bed in Thailand. Veterans needed to say goodbye to a life of being trapped in hell on earth and transition to a life of civility and freedom. To say goodbye to the buddies lost in combat, the ones who laid down their lives for you. To say goodbye to their life saving protective factors. The same factors that would be their undoing as civilians. A soldier’s training to kill sometimes translates to a life of crime in the civilian world. For the most part, combat was experienced in group and was able to be endured by the dream of returning home to a group: sweethearts, families, communities, and jobs. The reentry to these civilian groups was often more difficult to navigate, than was imagined.

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I was at the age, around pre high school and high school when I was dying to hear about my Dad’s war experiences. I wanted to know the details of what he had survived and the ways that he had survived it. I wanted to learn the way he had been trained in hand to hand combat. It was so important for me to know how a man becomes a warrior. This he would not share. I’m not sure why he kept these stories to himself, but my guess is that it was a combination of his attempt to protect his family, his guilt and shame about what he had to do to survive, and a belief that the best thing was to leave the past in the past. The stories that he did share were very different and remained indelible in my memory. He told the story of Pop Seapate with a deep caring and reverence, that made his eyes tear up. Pop was an older father figure to the younger guys in the platoon. I fell in love with Pop Seapate when I heard the stories and saw my Dad’s love for him. Telling me about Pop, put my Dad in a place that was safe, spiritual, and deeply moving. The memory of Pop and other close buddies served my Dad for many years after they were gone. These memories protect, serve, and inspire veterans for many years after war. Combat veterans share one of the most intense experiences that a human being can have. Vietnam veteran rap groups became popular, as a result of “not having been able to make sense of their past anywhere else” (Egendorf 1975). These rap groups were attractive to veterans who were more comfortable in an informal, non-clinical, safe, and confidential group. When troops return from combat, it is an enormous challenge to adjust to civilian life. It’s a bit like being dropped on a foreign planet, one that you have a vague memory of, one that you long to be a part of, but one that is no longer what you left behind. You are no longer the person you left behind. Your entire being was consumed by events that can only really be understood by someone who has experienced them. You go from being surrounded by only military to being a minority of less than 1% (the percentage of veterans of the US population). Those who are asked to do that which no human being should ever have to do. So much has been given up in war, but most of all a morality to kill. Being trained to kill another human with great skill and a lack of compassion can be morally and spiritually devastating. This sudden juxtaposition of environments upon coming home, has left many veterans totally disoriented. Many veterans

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spend a lifetime haunted by what happened. “22 veterans kill themselves per day, roughly one per hour” and the rate of PTSD has increased by 4,000%, as reported in VA Research Currents, Research News from the U.S. Department of Veterans Affairs in February 4, 2015 by Dr. Lori Johnson. These are alarming statistics. At one time there were more veteran suicides than deaths in combat. “The appeal of group interventions for PTSD rests, to a large extent, on the clear relevance of joining with others in therapeutic work when coping with a disorder marked by isolation, alienation, and diminished feelings.” (Foy 2000). As a veteran group participant stated, “All the words in the world cannot explain it. You can’t understand unless you feel it, having a group of people who are like me and have gone through what I have gone through.” The usual “socializing techniques” are fast tracked, (Rutan 2014b). An opportunity for new attachment solutions is born in group. The group experience can mimic the intense bonding veterans have experienced in combat, a shared experience. The life altering shared experience of combat engenders a level of respect, admiration, empathy, and compassion at an early stage. It is as if receptor sites have been eloquently and indelibly established in the veteran and they are best filled by another veteran. Veterans benefit from witnessing others in the group who have navigated themselves to a better place. Research continues to show that a veteran is “especially appreciative of the feedback from his peers and for the opportunity to bond with other veterans” (Ruzek 2001). This bond also provides a greater assimilation of the skills of awareness, skills that are unconsciously absorbed like a sponge. Groups help veterans reorient and build resilience. The process of building resilience is both multilayered and multifaceted, the result of many corrective life events, supports, and attachments. “Attachment solutions” that pale in comparison to the enormous “separation challenges” (Frichionne,) veterans endure during and after combat. Groups are a unique, rich, and fertile environment for resilience to grow. Groups are, in and of themselves, in the moment, healing as the corrective life events unfold in other group member’s, providing a safe place for openings and possibilities in new directions. The unspoken bond of veterans begins to repair. As was noted by the Boston-Threshold Group… “group therapy, support groups and community are key instruments in enabling individuals traumatized by war to find healing” (Northern Ireland Group Psychotherapy

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Conference description, n.d., paragraph 2) (Schulte 2014). It is also often the case that the witnessing of another’s resilience helps build one’s own resilience. Deepak Chopra refers to this process as “awareness mentoring”. “The most critical task of any combat trauma group is to create a safe holding environment, where it is possible to speak the unspeakable.” (Koller B236) When this is achieved, it provides deep attachments, interactions, and group cohesion. “…trust at each level is necessary before threatening information is revealed” (Rutan 2014b). This allows for and creates the needed safety to begin to share the dark secrets that have been the origins of such deep pain, suffering, guilt, and shame. This is especially true for Vietnam veterans who returned home to being spat upon and called baby killers. This is far different from WWII veterans, who also suffered horrible traumatic events, but who returned home as hero’s. It should be no surprise that, “the majority of veterans who die by suicide are over 50 years of age” (VA Research 2015). The layered experiences over time can be unbearable. Being part of a war that is impossible to justify, creates a level of guilt and shame that cannot be erased. The art of group therapy is in part the ability of the leader to choose how and when to encourage exploration away from a participant’s secure base attachment. While the cohesion of the group is much of what makes group therapy a natural fit for combat veterans, it also presents a limitation. “People who have not shared the traumatic experience cannot be trusted, because they cannot understand it. Sadly, this often includes spouses, children, and coworkers.” (Kolk). When and how does the group evolve so that members can include and trust others outside of the group? Veterans are encouraged to work through their trauma in a way that allows for greater connections outside of group, by encouraging community involvement. Maintaining heterogeneity of member’s longevity in group is one way for newer members to see the value of connecting outside of group. Members that have successfully made this transition are role models for newer members (Koller 1992). The group leader is also challenged with the veterans’ balance of focus and attachment to the there-and-then of the trauma and the here-and-now emotional response. Freud’s concept of the repetition compulsion can be especially strong and alive with veterans. This part of the psyche that we do not know, but continue to repeat. That which

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is inaccessible without outside observation. Each group member’s unique observation, opinion, and communication provides the veteran with a variety of ways to access “out-of-awareness” material. Group feedback can be unique in revealing and interrupting the repetition compulsion. The need to be in relationship beyond the secure base attachment of the group; to include family, friends, and loved ones, can be a natural progression of group, “in the primacy of group interactions, flexibility develops that allows discussion of relevant outside events in the members lives” (Rutan 2014b). The more that group members explore and relate their experiences of connecting positively with community-based supports, the more the ideas normalize. As these outside events surface, the group facilitator can assist in linking “the outside problem with their in group experience of the individual behavior” (Rutan 2014b). As the important links are made in group there is the beginning of trust of those outside the group. At this point the veteran can perhaps internalize the value of involving himself in couples’ therapy, individual therapy, AA meetings, church groups, Smart Recovery, etc. “The level of secure attachment that arises from membership and a safe place permits risk taking as a result of such internalization” (Rutan 2014b). It is also important to give group members “control over treatment goals” (Snell 1997), which follows the initial de-pathologizing of therapy and conversations about the fears of stigmatization of a disorder. Veterans have all experienced some degree of trauma and this can create a feeling of detachment or estrangement from non-veterans. Veterans groups address this by facilitating survivors helping survivors. When the survivors include the group facilitator in support/rap groups, such as those created by the Veterans Administration, where Vietnam veterans were hired to assist other veterans in group (Snell 1997), it seems to engender one of Yalom’s key principles in process--the installation of hope. This hope springs from the group realization that I'm not alone (“universality,” another of Yalom’s curative factors). Titrating the in group experience of trauma challenges just enough to be able to “side with growth not with pathology” (Rutan 2014b). The composition and character of Vet To Vet (VTV) support/rap groups may call for a hybrid approach. The attempt to combine, structural integrity, an informal atmosphere, the anonymity of an AA meeting, a psycho-educational component, and the psychodynamic backdrop of transferential

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and affective sensitivity to the in group exchanges. In our community surveys the one item that all participants identified as important was to have speakers who are veterans that have dealt with substance-abuse, PTSD, or other symptoms of trauma. This psycho-educational piece can provide a valuable steppingstone for the veteran. Becoming more vulnerable flies against all “combat ready” training and experience (Koller 1992). The informal experience of the support/rap group hopes to replace the World War II extended shipboard trips home. This experience provided a step down, a safe place, and a chance to drop their guard. Overcoming the military ingrained John Wayne tough guy image, without leaving the veteran too exposed is often a natural evolution of the group. However, cultural norms and military training dies hard. What began as a survival mechanism has become a barrier to recovery and reintegration to civilian life. The ingrained pride and strength of a combat veteran can be a way to access the vulnerable side of the veteran. As exhibited in the challenge of outdoor ropes courses, etc. The challenge defuses the inner time bomb. It is helpful to have a degree of heterogeneity of group members and homogeneity of experience. “… heterogeneity among group member’s highlights differences of veterans’ combat experiences, enhances generalization of therapeutic outcome, and ultimately increase his tolerance of others outside the group. Conversely, homogeneity with regard to at least some combat experience facilitates identification and bonding with other members, validates much of the reality of the experience, triggers association and release of repressed memories, and aids in identification and confrontation of PTSD and distorted memories. It is also desirable for group to be homogeneous in terms of overall levels of ego strength.” (Koller 1992). The need for veterans to have similarity of experience differs. Some veterans want to be sure that only combat veterans are in the group. Respecting this aids in bonding the group members. The groups that can bond among members and with the group facilitator are groups that will be abler to hold the drama and conflict in later sessions. When the elements of bonding are absent from the group, veterans are much more apt to experience greater conflict. Conflict that the group is unable to metabolize, normalize, and become stronger from. While the conflict may be the same at any point in time, the ability of the group to use the conflict as a unifying force as opposed to disruptive force, differs greatly at different stages of the group.

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Given that exposure is a component of most therapies for PTSD trauma, it is especially important that the group develop and maintain safety, cohesion, and bonding to a sufficient degree to withstand exposure to the trauma. The goal being to make exposure a more unifying force than a disruptive force. Trauma Focused Group Therapy (TFGT) (Ruzek 2001) is a therapy that has been widely used for veterans suffering with PTSD. There are different versions of TFGT and little empirical information to evaluate its efficacy. As with many therapies designed to deal with PTSD, exposure to the traumatic experience is at the core of treatment. The cautionary piece of this therapy is that the exposure to traumatic memories or the flooding procedures will cause veterans symptoms to worsen (Ruzek 2001). While it is true that any therapy that has exposure as one if its primary components runs the risk of increasing the patients’ distress, the increase in symptomology can also have great therapeutic value. The best result is that the group stays together and works through the experience together. “In this environment there is a perception of safety that aims to increase the capacity of each patient to tolerate exposure” (Schnurr 2001). However, some veterans do not tolerate exposure and will not participate or will drop out. Gestalt therapy is a treatment that has been found to be useful with veterans experiencing symptoms of PTSD. Although this work does not use exposure as a technique, Gestalt therapy does use reenactment. Here, the therapist encourages the veteran to fully express feelings associated with the trauma as opposed to talking about the trauma (‘Aboutism’), according to Pearls (1973), ‘Aboutism’ is an act of the intellect which we often times participate in (especially in traditional psychotherapy) as a defense against confronting the feared” (Crump 1984). It is important that the veteran find closure and finish what has been left unfinished from the past. Without finishing or finding closure, the veteran remains in the past and is unable to be fully present. For this work to be successful the therapist needs to have training in psychotherapy and specialized training in Gestalt therapy. Additionally, “the need to move slowly and cultivate a close, trusting relationship cannot be over emphasized” (Crump 1984). Psychodynamic group therapy for PTSD focuses on the here and now affective, transferential, and counterttransferential reactions of group members as the trauma is expressed. The circumstances surrounding the trauma, as well as events prior to and following the trauma are

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examined. Ideally the safety of the group allows the group leader and participants to point out and question what may not make sense in the veteran’s story. It is therefore very important to be sure that each group member is appropriate for the group, and “to the degree possible, the integrity of an individual’s presentation should be examined carefully” (Foy 2000). The more experienced the leader is in the psychodynamic approach, the more his/her observations in the moment will be able to identify thoughts feelings and behaviors that can then help the veteran to extrapolate to relationships outside of the group. This is the “working through…. that the patient connects in group insights with the real world experiences in a way that his personal network is obviously enriched.” (Rutan 2014b) In my experience, the best approach for veteran group therapy is eclectic in theory and application, with a sensitive and perceptive psychodynamic stance. A therapist can use a focused linear approach but will also need to adjust to the group to be the most helpful. A patient may want structure to begin with, but at some point will want a therapist who can recognize what is impacting the patient most (following the affect) and provide the gentle suggestions that allow for self-exploration.

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References

Brende, J. (1981) Combined Individual and Group Therapy for Vietnam Veterans. Int. J. Group Psychotherapy., 31(3), APR. 1981 Brockway, S. (1987). Group Treatment of Combat Nightmares in Post-Traumatic Stress Disorder. Journal of Contemporary Psychotherapy (Vol. 17, No. 4, Winter 1987). Crump, L. (1984). Gestalt Therapy in the Treatment of Vietnam Veterans Experiencing PTSD Symptomology. Journal of Contemporary Psychotherapy (Vol. 14, No. 1 Spring/Summer 1984). Egendorf, A. (1975). Vietnam Veteran Rap Groups and Themes of Postwar Life. Journal of Social Issues. (Volume 31, Number 4, 1975). Foy, D., (2002) Ruzek, J., Glynn, S., Riney, S., Gusman, F. Trauma Focus Group Therapy for Combat-Related PTSD: An Update. JCLP/ In Session: Psychotherapy in Practice, Vol. 58(8), 907-918 (2002). Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10066. Foy, D., (2000) Schnurr, P., Weiss, D., Wattenberg, M., Glynn, S., Marmar, C., Gusman, F. Group Psychotherapy for PTSD. Clinical Treatment of PTSD. Goodman, M., (1998) Weiss, D. Double Trauma: A Group Therapy Approach for Vietnam Veterans Suffering from War and Childhood Trauma. International Journal of Group Psychotherapy. ISSN: 0020-7284 (Print) 1943-2836 (Online) Journal homepage: http://www.tandfonline.com/loi/ujgp20. Junger, S., (2016) Tribe: On Homecoming and Belonging. Hachette Book Group. 1290 Avenue of the Americas, New York, NY 10104 (May 2016). Kolk, B. Group Psychotherapy with Posttraumatic Stress Disorder. Group Psychotherapy with Special Populations, D.16. Koller, P., (1992) Marmar, C., Kanas, N. Psychodynamic Group Treatment of Posttraumatic Stress Disorder in Vietnam Veterans. International Journal of Group Psychotherapy, 42(2) 1992. Motherwell, L., Shay, J. Complex Dilemmas in Group Therapy Pathways to Resolution. Treating Difficult Patients in Groups, J. Scott Rutan. Routledge Taylor & Francis Group. New York and London. Parson, E. (1988) The Unconscious History of Vietnam in Group: An Innovative Multiphasic Model for Working Through Authority Transferences in Guilt- Driven Veterans. Int. J. Group Psychotherapy., 38(3), July 1988.

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Rozynko, V., (1991) Dondershine, H. Trauma Focus Therapy For Vietnam Veterans With PTSD. Psychotherapy. Volume 28/Spring 1991/Number 1. Rutan, J., (2014a) Things That I Have Learned: 45+ Years of Group Psychotherapy. International Journal of Group Psychotherapy, 64(4) 2014. Rutan, J., (2014b) Stone, W., Shay, J. Psychodynamic Group Psychotherapy. The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012. www.guilford.com Ruzek, J., (2001) Riney, S., Leskin, G., Drescher, K., Foy, D., Gusman, F. Do Post- Traumatic Stress Disorder Symptoms Worsen during Trauma Focused Group Therapy? Military Medicine; Oct. 2001; 166, 10; ProQuest Central. Schulte, R., (2014) Lovett, H., Rice, C., Williams, R., The Power of the Group in Northern Ireland. International Journal of Group Psychotherapy, 64 (4). Schnurr, P., (2001) Friedman, M., Lavori, P., Hsieh, F. Design of Department of Veterans Affairs Cooperative Study No. 420: Group Treatment of Posttraumatic Stress Disorder. Control Clinical Trials 22:74-88 (2001). Elsevier Science Inc. 2001. Scurfield, R., (1984) Corker, T., Gongla, P., Hough, R. Three Post-Vietnam “Rap/Therapy” Groups: An Analysis. Group, Vol. 8, No. 4 (Winter 1984), pp. 3-21. Stable URL: http://www.jstor.org/stable/41718251. Shapiro, R. (1978) Working Through the War with Vietnam Vets. Group, Vol. 2, No. 3 (Fall 1978), pp. 156-183. Eastern Group Psychotherapy Society. Stable URL: http://www.jstor.org/stable/41717923. Shatan, C., (1973) The Grief of Soldiers: Vietnam Combat Veterans’ Self-Help Movement. Amer. J. Orthopsychiat. 43(4), July 1973. Snell, F., (1997) Padin-Rivera, E., Group Treatment for Older Veterans with Post- Traumatic Stress Disorder. Journal of Psychosocial Nursing 1997, Vol. 35, No.2. VA Research Currents, Group Therapy Shows Promise for Suicidal Veterans (2015). Office of Research and development. Walker, J., Comparison of “Rap” Groups with Traditional Group Therapy in the Treatment of Vietnam Combat Veterans. Group, Vol. 7, No. 2 (Summer 1983), pp. 48-57. Eastern Group Psychotherapy Society. Stable URL: http://www.jstor.org/stable/41718189. Williams, T., A Preferred Model for Development of Interventions for Psychological Readjustment of Vietnam Veterans: Group Treatment.